Population Health News

Bringing the Patient-Centered Medical Home into the Community

April 17, 2015 - If there’s one thing to keep in mind about the patient-centered medical home as HealthITAnalytics.com concludes its practice transformation series, it’s that the PCMH is about so much more than checking off boxes on a recognition framework or purchasing the right population health management technologies just to dazzle competitors and peers.

The patient-centered medical home is a deep, broad, and challenging commitment to improving the lives of patients in every way possible – and for PCMH providers, that means the work doesn’t stop once the patient pulls out of the parking lot.

Developing meaningful relationships and dialogues with the wider community, including public health departments, pharmacies, long-term care and home care providers, schools, behavioral healthcare providers, and workplaces, is a crucial factor for PCMH success. “Health primarily happens outside the doctor’s office—playing out in the arenas where we live, learn, work and play. In fact, a minority of our overall health is the result of the health care we receive,” National Coordinator Karen DeSalvo, MD, MPH, MSc reminded the healthcare community last year.

Providers who are dependent on behaviors like medication adherence and chronic disease management for an increasing proportion of their revenue must understand how patients make health decisions in their daily lives and what can make it easier for them to choose the right paths. Through a combination of health IT tools and care coordination techniques that leverage a human touch, patient-centered medical home providers can establish meaningful working relationships with the numerous organizations that impact patient health.

What are the most important aspects of a community-based population health management program, and how can the patient-centered medical home become a coordinating hub for the social dimension of quality healthcare?

Taking an analytics-based approach to population health management allows providers to strategically target pockets of chronic diseases, areas of economic insecurity, neighborhoods with physician shortages, and places where immunizations are low or infectious diseases are likely to incubate.

Thanks to the EHR Incentive Programs, nearly three-quarters Stage 2 meaningful use of hospitals are actively contributing public health data to their local agencies, and 48 percent of hospitals that provide urgent care services are reporting syndromic surveillance data to public health organizations. These numbers are set to increase as more organizations meet the reporting requirements of Stage 2, illustrating yet another way that the patient-centered medical home can benefit from these regulatory efforts.

“The first priority of local health departments is to make it easier for people to be healthy and safe,” said Roland Gamache, PhD, MBA, Senior Director of Informatics at the National Association of County and City Health Officials (NACCHO) when HIMSS released its Public Health and HIE Toolkit in 2014. “Health information technology increases the capacity of local health departments to be able to do that.”

One of the top reasons why chronic disease patients land in the hospital again and again is a lack of medication adherence, studies have repeatedly found. Non-adherence is one of the mostly problems the healthcare system faces, but it’s also a problem that providers can help control to some degree. Reducing barriers to medication access and ensuring that patients understand how and when to take their pills can have immediate and measurable impact on costs and patient outcomes, and the patient-centered medical home already has many of the necessary tools in hand.

The EHR is a powerful player in the battle to improve adherence. In the Kaiser Permanente system, EHR data mining helped to flag patients who were non-adherent to their diabetes and heart disease drugs, which allowed care coordinators to follow up with letters and calls. These activities produced a two percent increase in adherence in just twelve months.

Use of a patient portal helped other providers bump up diabetic medication adherence by six percent, another study found. “Medication adherence and other health behaviors are often the hardest things for health care providers to influence,” said senior author Andrew J. Karter, PhD, research scientist at the Kaiser Permanente Division of Research in Oakland, Calif. “Our study showed that when patients used online prescription refills, it can improve adherence and health outcomes. On top of those benefits, we know that online refill systems increase the efficiency of pharmacy operations and provide more convenience for patients.”

Leveraging the EHR for better medication adherence and care coordination for chronic disease patients is as easy as participating in e-prescribing. A recent survey of elderly patients in Pennsylvania found that 82 percent of Medicare-aged seniors expect and prefer electronic prescriptions, which allow them to spend less time waiting for medication refills at the pharmacy, ensure accuracy, and reduce confusion over what has been prescribed and when it needs to be renewed.

It’s no secret that economic insecurity is one of the biggest drivers of poor lifestyle choices and one of the major factors in the development of chronic diseases such as obesity, diabetes, and hypertension. Patients who live in low-income areas often lack access to healthy food, places to exercise, means of transportation to healthcare providers, and education about the impact of their daily decisions on their long-term health.

In one study, diabetic patients facing housing instability, food insecurity, and uncertainty about keeping their utilities on were more likely to report less control of their disease and more frequent visits to outpatient providers. In another, patients facing similar issues were twice as likely to require diabetic amputations as their wealthier counterparts.

Many of these socioeconomic circumstances are beyond the control of a healthcare provider, but the patient-centered medical home is designed to help patients overcome these obstacles. Community outreach, coaching, expanded access, and care coordination are built into the model, and provide opportunities to help close gaps between a patient’s resources and her needs.

“We can predict fairly well which patient is likely to get in trouble from their clinical situation, but their social determinants are just as important,” said Ann Hendrich, Senior Vice President and Chief Quality and Nursing Officer at Ascension Health, a large health system that takes a patient-centered approach to population health management. “Do they have access to the primary care? Do they have resources in the community, whether it’s help with their prescriptions or meal support or help with the activities of daily living?”

“Right now, I think you’ll find every system in the country is working on those care models of the future, and that will require our partners to think differently with us and be ready to enable the workflows that will be necessary for that.”

The patient-centered medical home can take these social determinations into account when helping patients develop self-care plans. The NCQA PCMH framework requires providers not just to use EHRs to stratify risk, but also to sit down with patients and their care givers to provide condition-specific education, document the abilities and resources of vulnerable patients, and deliver education and counseling to at least half of their population about how to adopt healthier lifestyle behaviors and make more positive choices at the grocery store, the office snack machine, the tobacco shop, and the gym or park.

Collaborating for continuous improvement

The patient-centered medical home may be the nucleus of a community of care, but the spokes are just as important as the hub. Schools and workplaces often bear a great deal of responsibility for the health and wellness of the people who spend time there, and healthcare providers must collaborate with these organizations in order to ensure that patients are receiving quality services throughout their journey to health.

The school nurse has been a fixture of the educational system since its inception, but they can do much more than take temperatures or stick bandages on scraped knees. Full-time school nurses can save twice as much as they cost, a JAMA study found, saving $20 million in care costs and $28 million in prevented parent work losses each year. When telehealth is introduced into the equation, disruptions to families and educators are further reduced, and children get the primary and acute care they need without missing classes.

“School-based telehealth programs will allow students to see their health care provider without taking time away from school,” said Rachel Mutrux, program director for the Missouri Telehealth Network, after the introduction of a bill in January that would allow Medicaid reimbursement for school-based telehealth. “With parental consent, students with conditions such as asthma, diabetes or even an ear ache could receive timely treatment through the use of video technology and other tools specifically designed for telemedicine.”

Meanwhile, employers who are shouldering enormous costs to insure their patients are seeking help from payers and providers to cut down spending by trimming waistlines, encouraging exercise, and investing in mental health and chronic disease management programs. Sedentary office workers who spend a third of their day at their desks are at risk for poor health outcomes that foist high costs onto their employee health plans.

At Hawaii National Bank, for example, “diabetes and cardiovascular care are the two biggest health issues,” explained Derek Kanehira, Vice President of Human Resources. Using healthcare data analytics, HNB formed a strategy for addressing its employees’ chronic health needs with the help of willing providers.

“We partnered with a local hospital system and asked them to sit and talk with our employees about their health numbers, as well as talk to them about the support that’s available. This year, 100 percent of our employees completed both a biometric screening and health risk assessment, and we’ve seen large increases in our on-site chair massages and monthly lunch and learn sessions.”

Patient-centered medical homes shouldn’t just be aware of what activities their patients are engaging in when they’re at school or work. They should be actively reaching out to these partners in health to understand the needs and effectiveness of these programs.

Collaborating with community resources can extend the reach and impact of all members of the care continuum, traditional or not. With the PCMH’s emphasis on continuous improvement, primary care providers cannot afford to work in isolation. Going above and beyond the confines of the physician’s office to help patients access to the social resources they need to actively take part in improving their own health is a crucial part of ensuring that the patient-centered medical home is a truly patient-centered initiative, and is one of the most important steps in the process of practice transformation.